Elliscombe House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team had a shared vision, strategy and had developed a positive culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The management team were passionate about improving people’s experience of living in the service. One person told us, “I’ve been in three homes, and this is the best.” Another person said, “It’s a good home. I mean also in the sense of it being a ‘home’.” One staff member said, “The management team are amazing."

The management team were all inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager was a very experienced nurse, but this was their first post as a registered manager of a nursing home. They were not being mentored, adequately supported or helped to develop in their role. This was also raised as a key point by the local authority and health authority quality assurance teams. They stated, “[The registered manager] should be having frequent, minuted supervision due to her high pressure role and responsibilities. It is advised [they] receive some form of clinical supervision.” The owner was unable to provide this level of support to the registered manager.

The registered manager told us they had no formal support or supervision. They had been asked to write their own support and development plan by the owner. This plan included the supervision, training and education the registered manager felt was essential to enable them to perform their role confidently and effectively. None of this plan had been actioned by the owner. This must be addressed as a matter of urgency.

People and staff were complimentary about how the registered manager ran the service and the improvements they had made. People felt they experienced a good quality of life. People and staff told us the registered manager was approachable, led by example and had significantly improved the home. One person said, “The quality of care has really improved since we have had the new manager.” One staff member said, “I like it here now. [Name] is the best manager ever. She is making lots of changes and teaches us.”

The registered manager told us they had worked extremely hard to create an open, respectful and honest culture. Staff told us they could share ideas or raise concerns with any of the management team. One staff member told us, “All of the managers are good. They help on the floor and are friendly. I would give them 5 stars."

The management team had developed and fostered a positive culture where people felt they could speak up and their voice would be heard. People, relatives and staff told us they felt confident to raise concerns with the management team and these would be listened to and acted upon. One person said, “I haven’t been asked for feedback personally, but I do know that they take minutes at the resident’s meeting, which is held once a month.”

Staff felt their views and suggestions were actively taken on board. A staff member said the management team was, “Amazing and built morale."

The management team valued diversity in their workforce. The registered manager ensured there was an inclusive and fair culture.

Through talking with people, relatives, staff and members of the management team, we found care and support was delivered in a non-discriminatory way and the rights of people with a protected characteristic were respected. Protected characteristics are a set of nine characteristics that are protected by law to prevent discrimination. For example, discrimination based on age, disability, race, religion or belief and sexuality.

At the last assessment we found the provider had failed to operate effective systems to assess, monitor and improve the quality of care people received. At this assessment we found improvements had been made.

Quality assurance processes had been significantly improved. These needed to be refined so the overall governance system would hold staff to account, keep people safe, protect people's rights and ensure consistent, good quality care and support.

There were a series of quality assurance checks in place to review the performance of the service. These included a clinical audit, accident and incident reviews, risk reviews, and a review of any complaints and compliments. However, further improvements in auditing would ensure issues such as lack of required repositioning of people would not recur. This was discussed with the management team who will make the necessary improvements.

A staff survey had also been completed in January 2025. All of the quality assurance checks and the survey had fed into the service improvement plan. This plan was reviewed every week at one of the heads of department meetings to ensure improvements were carried out and monitored.

The management team understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The registered manager told us how they had worked closely with both the LARCH (Listening And Responding to Care Homes) team (a support service that worked across the county to improve health outcomes for people in care homes) and the local authority and health authority quality assurance teams. These teams had supported the improvements made throughout the service since our last assessment. The quality teams had commented they, “Would extend their commendations to the entire staff team for their unwavering dedication to making positive change. Thank you for your continued efforts and commitment.” The home had been visited by staff from Healthwatch Somerset (an independent health and social care body) in June 2025. Their key findings were positive.

The management team were clearly focused on continuous learning and improvement across the organisation and local system. They wanted good outcomes and a good quality of life for people. They had developed safe and effective care practices. Discussions with the management team and staff demonstrated they recognised the importance of learning lessons and continuous improvement to ensure people received care and support that was safe and effective.

The management team used information from feedback, audits, complaints, incidents and safeguarding alerts to improve the service. The management team worked with staff to understand what happened if things went wrong and involved them in finding solutions to prevent recurrence.